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  • 1. NHS 4winningprinciples NHS Improvement Cancer Inpatients Case Studies Oncology Patients Admitted as Emergencies Assessment prior to admission – Baseline Audit and Testing of Two Models Defined of Care at the Royal Berkshire Hospital inpatient pathways Introduction Baseline Audit Findings The project was developed in response to a call for 10 patients admitted as emergencies applications as testing sites from the Cancer Services 31 Collaborative Improvement Partnership. 3 haematology patients Daily decision making The overall aim of this national scheme is to improve the 7 oncology patients experience of in-patient care for oncology patients, reduce overall length of stay and improve in-patient pathways. 5 in hours (9-5) Encourage self The successful application from the Royal Berkshire 5 out of hours management Hospital proposed a baseline audit to assess the length of stay for patients admitted as an emergency and to also Presenting Problem assess the length of time from admission to review by an oncology doctor. Within the baseline a comparison was made with haematology patients as haematologists at the Royal Berkshire operate a ‘haematologist of the week’ system whereby a consultant is freed from clinic commitments in order to carry out daily ward-rounds and review patients admitted as emergencies. Diagnosis It was postulated that oncology patients admitted as emergencies were under the care of the ‘on take’ medical teams and there were frequently delays in oncologists being informed that their patients were in the Trust, despite the fact that these patients were undergoing active oncological programmes of care. It was also postulated that these delays could result in extended in-patient stays. Following the baseline audit two models of delivering care Time from admission to being seen by to cancer patients admitted as emergencies were tested oncologist and audited over periods of one week (including one Average time for weekend) Haematology = 23hrs (range 12 to 46) Average Time for • Model 1 – a consultant ‘oncologist of the week’ would Oncology = 41hrs (range 1 to 72) assess patients with oncological problems as close as possible to their admission to the Trust and would relinquish clinic commitments in order to do this. • Model 2 – the Nurse Consultant, together with an oncology Clinical Nurse Specialist would triage emergency admissions and provide a ‘signposting’ service to oncology teams and other health care professionals Neither of these models included any ‘out-of-hours’ or weekend cover and were subjected to continuous audit.
  • 2. Oncology Patients Admitted as Emergencies – Baseline Audit and Testing of Two Models of Care at the Royal Berkshire Hospital Length of Stay – Baseline Diagnosis Average LOS Haematology = 88 hrs (range 72 to 120hrs) Average LOS Oncology = 185 hrs (range 72 to 360 hrs) Time from admission to being seen by oncologist – Model 1 Key Features of the Data Average time in • Both the waiting time to be seen by specialist team and baseline = 41hrs (range 1 to 72) length of stay longer in oncology. It is likely that awareness Average time for that the patient has been admitted is an important factor. Model 1 = 9.5 hrs (range1.5 to 30) • Only one patient able to be admitted to bed on oncology/haematology ward – patient with shortest wait. 90% of patients were outliers. It is likely that the location of the patients is important in obtaining a specialist review. • High proportion of breast cancer patients with neutropaenic sepsis (3) and lung patients with increased shortness of breath (2) • Shorter length of stay than HES data – due to acute nature of Length of Stay – Model 1 this sample with 6 patients being admitted with neutropaenic Average LOS sepsis. baseline = 185 hrs (range 72 to 360 hrs) Average LOS Model 1 Testing Findings – Oncologist of the Week Model 1 = 203 hrs (range 26 to 336) 11 patients admitted as emergency 6 ‘in hours’ (9 to 5) and 5 ‘out of hours’ 4 patients subsequently found not to have an oncological reason for admission Key Features of Data from Model 1 Additional workload in reviewing patients already seen and • Much less acute sample of patients than in those on the oncology ward (15 other reviews across the week) baseline. No admissions with neutropaenic sepsis. Two deaths in this sample, this Presenting Problem likely to have increased length of stay. • Time to oncology review dramatically decreased by 75% from baseline. • No overall reduction in length of stay from baseline. This likely to reflect patient group rather than care received • Large additional workload (15 additional consultations) for consultant in reviewing patients already seen (as these had not been taken over by oncology) and reviewing sick patients on oncology ward. Model 2 Testing Findings – Nurse Consultant Plus CNS 10 patients admitted as emergency 7 in hours and 3 out of hours. 2
  • 3. Oncology Patients Admitted as Emergencies – Baseline Audit and Testing of Two Models of Care at the Royal Berkshire Hospital Presenting Problem Key Features of data from Model 2 • More balanced sample in terms of acuity. One patient with newly diagnosed brain metastases, one patient who was transferred to hospice. Two patients with possible neutropaenic sepsis. • Very little additional workload other than seeing patients for assessment (3 other consultations for reviewing patients seen on admission) Diagnosis Report On Audit Of Prototype Of Oncologist Of The Week at The Royal Berkshire Foundation Trust (May 2008) In late 2007 an audit was carried out to explore the effect of introducing of an ‘Oncologist of The Week’ system on the waiting times emergency oncology patients experienced before obtaining a specialist review, and also any effect on the overall length of stay for this patient group. The ‘oncologist of the week’ system was based Time from Admission to First seen by Service and Oncologist on the system employed within the RBFT by the haematology consultant body whereby a Average time in baseline = 41hrs (range 1 to 72) consultant was relieved of clinic duties for a Average time in phase 1 = 9.5 hrs (range1.5 to 30) week and reviewed all admissions and ward Average time in phase 2 patients (including outliers). (Nurse Consultant/CNS) = 13 (range 1 to 34) Average time in phase 2 (Oncologist) = 22 (range 6 to 36) In this audit it was demonstrated that the ‘oncologist of the week’ system did drastically reduce the time patients waited for an oncology review but did not appear to reduce the overall length of stay. As the baseline group in the original audit was unusually acute it was decided to repeat the audit. Each audit period was carried out over one week (week-days only). The oncologist of the week data only has Length of stay – Model 2 patients admitted over three week days due Average LOS baseline = 185 hrs (range 72 to 360 hrs) to a days lost to a bank holiday and to other Average LOS phase 1 = 203 hrs (range 26 to 336) consultant commitments. The results are Average LOS phase 2 = 183 hrs (range 24 to 360) shown below. Audit May 2008 – Baseline – 11 patients 1) Presenting Condition 3
  • 4. Oncology Patients Admitted as Emergencies – Baseline Audit and Testing of Two Models of Care at the Royal Berkshire Hospital 2) Diagnosis 2) Diagnosis 3) Length of wait to review Average = 14.5 hrs 3) Length of wait to review Average wait = 48.1 hrs 4) Length of Stay (LoS) Average LoS = 151 hrs 4) Length of stay (LoS) Average LOS = 177.5 Key Features of The Data The baseline and the sample of patients seen by the ‘oncologist of the Week’ would appear to be better balanced in terms of acuity than in the original audit with three patients in each group being admitted with possible sepsis. There would appear to be a ‘Oncologist of the Week’ reasonable spread of patients across the 1) Presenting condition – 11 patients tumour groups although, unusually there were no patients with lung cancer or mesothelioma admitted in the ‘oncologist’ group. The average length of stay in the group seen by the ‘oncologist of the week’ had a considerably shorter length of stay than those in the baseline group. Combined data If the data from both baseline audit weeks and both ‘oncologist of the week’ audit weeks the results can be seen below. 1) Baseline Patients = 17 Wait to review = 45.3 hrs Average LoS = 180 hrs 4
  • 5. Oncology Patients Admitted as Emergencies – Baseline Audit and Testing of Two Models of Care at the Royal Berkshire Hospital 2) Oncologist of the Week Patients =22 Wait to review =12hrs Average LoS = 177 Other Issues During this audit the oncology consultant saw a higher number of patients per day than on previous audits, this can be illustrated by the fact that 11 patients were seen in 3 days rather than 5. The consultant performed an additional 15 reviews on patients who had already been seen by the service, patients on the ward and reviews requested by other doctors. The feedback from other clinicians was very positive, particularly nursing and medical staff in Accident and Emergency, the Clinical Decision Unit and the short-stay admissions ward. One medical consultant, however believed that there was some repetition of work-load between the Oncologist of the Day and the ‘Physician of the Day’ covering CDU. The computer was available in order to access cancer centre notes system which increased efficiency. Discussion There can be little doubt that the operation of an ‘Oncologist of the Week’ system does dramatically reduce the length of time patients wait for oncology opinion when admitted as an emergency. If this audit is taken in isolation it would suggest that there could be a possible benefit from reducing Length of Stay from an early review by the Oncology teams caring for the patient. Even if the results from both audits are pooled there is still a reduction in length of stay although this is much more modest. I believe the main determining factor in the length of stay is the presenting condition. The general impression from other health care professionals and from patients and carers is that the service represents an improved service for patients admitted with oncological problems. The debate should now focus on Authors • Which group of clinicians should carry out this work and how Mark Foulkes should it be resourced Nurse Consultant/ • Is there a demonstrable improvement in quality other than a Trust Lead Cancer Nurse possible reduction in length of stay • What is the patient experience? Dr Jane Barrett Consultant Oncologist Outstanding Further Work Patient satisfaction/experience audit Dr James Gildersleve Consultant Oncologist Develop early warning system alongside the system 5